Investigation Finds Master Asleep at the Wheel in Washington State Ferry Accident

Investigators with the National Transportation Safety Board say the captain of the Washington State Ferry Cathlamet likely suffered from a bout of microsleep when the vessel struck a mooring dolphin at a Seattle terminal last year, causing more than $10 million in damages.

The National Transportation Safety Board (NTSB) released its report into the July 28, 2022 incident on Thursday, attributing the accident to fatigue and complacency.

According to the NTSB, the Cathlamet had just completed a crossing of the Puget Sound with 94 people on board and was approaching the Fauntleroy Ferry Terminal when it collided with the dolphin. Fortunately, only one minor injury was reported.

The investigation revealed that the ferry’s master, who was at the helm, had ceased rudder commands approximately 30 seconds before the collision. However, no corrective action was taken to adjust the ferry’s course, reduce speed, or sound an alarm.

The master also had no recollection of the events leading up to the collision and appeared unaware of how the ferry ended up striking the dolphin. Investigators concluded that these circumstances were consistent with the master experiencing a momentary lapse of consciousness known as a microsleep, likely caused by fatigue.

“Fatigue can have significant impacts on decision-making, alertness, and reaction time,” stated NTSB investigators in their final report. “Mariners need to understand the consequences of sleep deprivation and recognize the dangers of fatigue-related issues, such as microsleeps. When fatigued, mariners should arrange for a qualified watchstander to take over their duties and refrain from being on duty when they are unable to fulfill their responsibilities safely.”

In addition to fatigue, the NTSB highlighted complacency as a contributing factor in the accident. The Cathlamet’s bridge team failed to comply with Washington State Ferries’ policies during the docking and undocking procedures. Specifically, the quartermaster did not actively monitor the master as the ferry approached the dock, as required by company policy. This oversight prevented prompt intervention when the master became incapacitated.

“Complacency arises when operators repeatedly perform tasks without consequence, leading to a diminished awareness of inherent risks,” the report explained. “To combat complacency, operators should strictly adhere to established procedures, such as operating checklists, to mitigate single points of failure. Companies should also emphasize the importance of following procedures through comprehensive training programs.”

An internal investigation by Washington State Ferries previously found the Master had lost situational awareness for unknown reasons as the captain refused to answer any questions during the investigation. That investigation did rule out both drugs and alcohol.

The NTSB’s report serves as a reminder of the critical role fatigue management and adherence to safety protocols play in ensuring the safe operations of maritime transportation. It calls for increased awareness and proactive measures to address fatigue-related risks and combat complacency among ferry operators.

Marine Investigation Report 23-21 is available online.

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